Dental public health in action: The covid-19 restrictions on dentistry in England and their impact on access to dental care for high-risk patient groups in the North-East and North Cumbria.

The Covid-19 pandemic has significantly impacted dental practices with the initial response being a complete suspension of face to face care unless designated as an urgent care centre. Even with subsequent easing of restrictions, a significant change to the delivery of dental care is continuing to restrict patient access. The introduction of new Standard Operating Procedures, with a benchmark fallow time of 15 to 30 minutes after aerosol generating procedures, has also reduced capacity levels within dental practices. Triaging systems have been implemented within practices to ensure those with the highest oral health care needs are prioritised for face to face care. Altered patient attendance, due to the Covid-19 restrictions placed upon dental care, may also be compounded by patients avoiding dental care due to personal perceptions of risks associated with Covid-19 or due to a desire not to overburden health systems. With the additional Covid-19 restrictions in place the access to dental care for vulnerable populations may have been even further impacted, there is therefore a concern that the restrictions may have exacerbated inequalities in oral health for these groups. Public health competencies illustrated: Developing and monitoring the quality of dental services, Dental Public Health Intelligence, and Policy and Strategy Development are illustrated within this project.

Inequalities in orthodontic outcomes in England: treatment utilisation, subjective and normative need.

OBJECTIVE: To investigate inequalities in three aspects of access to orthodontic care: uptake of orthodontic treatment, normative need and subjective need in England. METHODS: We used data from two surveys in England: 12 and 15-year-olds from the 2013 Child Dental Health Survey (CDHS 2013) and 12-year-olds from the 2008/2009 NHS Dental Epidemiology Programme for England (NDEP 2008/2009). Summary variables representing orthodontic status were calculated. Two regression-based summary measures of inequalities were used to investigate the relationship between deprivation level and orthodontic outcomes: Slope and Relative indices of Inequality. RESULTS: There were significant absolute and relative inequalities in uptake of orthodontic treatment. The least deprived were 1.9 times more likely to have received orthodontic treatment compared to the most deprived in both surveys. Normative need was not associated with deprivation in either the analyses of CDHS 2013 (SII= 0.03, 95% CI: -0.04, 0.1; RII=1.06, 95% CI: 0.91, 1.24) or the NDEP 2007/2008 (SII= 0.03, 95% CI: -0.02, 0.07; RII=1.06, 95% CI: 0.96, 1.18). There was greater willingness to have teeth straightened in more deprived children from CDHS 2013 (SII=-0.09, 95% CI: -0.16, -0.03; RII=0.85, 95% CI: 0.75, 0.96) but not in NDEP 2007/2008 (SII=0.03, 95% CI: 0, 0.06; RII=1.07, 95% CI: 0.99, 1.15). CONCLUSIONS: Being deprived was associated with lower uptake of orthodontic treatment. Normative need was not related to deprivation. The association between deprivation and subjective need was only partly established, with poorer children showing a greater desire to have their teeth straightened in one survey.

Low rates of dental attendance by the age of one and inequality between local government administrative areas in England.

OBJECTIVE: To describe child dental attendance (DA) by 1 year of age in England and its relationship with area deprivation. BASIC RESEARCH DESIGN: Analysis of National Health Service data for the 12 months to June 2017. Deprivation was measured by Index of Multiple Deprivation Rank of Average Score (2015) for upper-tier and unitary local authorities in England (LAs, n=151). DA rates were calculated for children under 1 year (⟨1yr) and children aged 1 year and under (⟨1yr). A Spearman's test assessed strength of association with deprivation. The Slope Index of Inequality (SII) and Relative Index of Inequality (RII) explored equity. CLINICAL SETTING: Upper-tier and unitary LAs in England. MAIN OUTCOME MEASURE: Attending an NHS primary care dental service. RESULTS: DA rates ranged from 0 to 12.3% (Median:2; IQR:1.4,3.9) in children ⟨1yr and from 3.7 to 37.6% (Median:10; IQR:7.4,17) in children ≤1yr. DA rates decreased as deprivation decreased (Spearman=-0.25, p=0.0019 in children ⟨1yr; Spearman=-0.21, p=0.0104 in children ≤1yr). The SII suggested a 2 percentage point difference in DA rate across the deprivation distribution in children ⟨1yr (SII=-0.02, 95% CI=-0.01,-0.04; p=⟨0.001); and a 5 point difference in children ≤1yr (SII=-0.05, 95% CI=-0.02,-0.09; p=0.003). The DA rate in the most deprived LA was 2.1 higher than the least deprived LA (RII=2.1, 95% CI=1.4,3.2; p=⟨0.001) in children ⟨1yr and 1.5 higher (RII=1.5, 95% CI=1.2,2; p=0.004) in children ≤1yr. CONCLUSIONS: DA rates were low for all LAs and only partially explained by deprivation. More deprived LAs were, unexpectedly, more likely to report higher DA rates.

Dental Public Health In Action: Barriers to oral healthcare provision for older people in residential and nursing care homes: A mixed method evaluation and strategy development in County Durham, North East England.

This paper presents a case study on the use of mixed methods in research into practice to inform policy. The study was undertaken as part of a review of oral healthcare for older people in residential and nursing care homes in County Durham, North East England. The findings highlighted challenges in the provision of good quality oral healthcare to older people in residential and nursing care homes and informed the county's oral health strategy (Durham County Council DCC, 2016). Key recommendations include the need to develop and implement a minimum set of best practice oral health standards within care home contracts and train care home staff in oral healthcare. The paper relates to two key dental public health competencies: (i) designing and using mixed method studies to address gaps in evidence and triangulating the findings from quantitative and qualitative methods; (ii) the development of evidence based policies. The research is relevant to: care home staff; commissioners in local authority adult and social care; public health practitioners; oral health improvement teams; domiciliary and special care dentists, dental commissioners, researchers and academics.

An audit of antimicrobial prescribing by dental practitioners in the north east of England and Cumbria.

BACKGROUND: Inappropriate prescribing of antimicrobials is a significant threat to global public health. In England, approximately 5% of all antimicrobial items are prescribed by dentists, despite the limited indications for their use in the treatment of oral infections in published clinical guidelines. The objective of this study was to survey antimicrobial prescribing by dental practitioners in North East England and Cumbria, identify educational and training needs and develop a self-assessment tool that can be used for Continued Professional Development by individual practitioners. METHODS: During October 2016, 275 dental practitioners used a standardised form to record anonymous information about patients who had been prescribed antimicrobials. Clinical information and prescribing details were compared against clinical guidelines published by the Faculty of General Dental Practitioners UK. RESULTS: Dental practitioners provided data on 1893 antimicrobial prescriptions. There was documented evidence of systemic spread, such as pyrexia in 18% of patients. Dentists recorded patients' pain (91.1% of patients), local lymph gland involvement (41.5%) gross diffuse swelling (55.5%) dysphagia (7.2%) and trismus (13.6%). Reasons for prescribing antimicrobials included patient expectations (25.8%), patient preference (24.8%), time pressures (10.9%), and patients uncooperative with other treatments (10.4%). The most commonly prescribed antimicrobials were amoxicillin, accounting for 61.2% of prescriptions, followed by metronidazole (29.9%). Most prescriptions for amoxicillin were for either 5 days (66.8%) or 7 days (29.6%) and most prescriptions for metronidazole were for a 5-day course (65.2%) or 7-day (18.6%) course. CONCLUSION: In most cases, when an antimicrobial was prescribed, practitioners used the correct choice of agents and usually prescribed these at the correct dose. However, some evidence of suboptimal prescribing practices when compared to the Faculty of General Dental Practitioner guidelines were identified. The audit has identified training needs across the region and aided the development of Continued Professional Development sessions. Further work to identify barriers and facilitators for improving antimicrobial prescribing and determining appropriate methods to improve clinical practice are required.

Fractional urinary fluoride excretion of 6-7-year-old children attending schools in low-fluoride and naturally fluoridated areas in the UK.

F is an important trace element for bones and teeth. The protective effect of F against dental caries is well established. Urine is the prime vehicle for the excretion of F from the body; however, the relationship between F intake and excretion is complex: the derived fractional urinary F excretion (FUFE) aids understanding of this in different age groups. The present study aimed to investigate the relationships between (1) total daily F intake (TDFI) and daily urinary F excretion (DUFE), and (2) TDFI and FUFE in 6-7-year-olds, recruited in low-F and naturally fluoridated (natural-F) areas in north-east England. TDFI from diet and toothbrushing and DUFE were assessed through F analysis of duplicate dietary plate, toothbrushing expectorate and urine samples using a F-ion-selective electrode. FUFE was calculated as the ratio between DUFE and TDFI. Pearson's correlation and regression analysis were used to investigate the relationship between TDFI and FUFE. A group of thirty-three children completed the study; twenty-one receiving low-F water (0·30 mg F/l) and twelve receiving natural-F water (1·06 mg F/l) at school. The mean TDFI was 0·076 (SD 0·038) and 0·038 (SD 0·027) mg/kg per d for the natural-F and low-F groups, respectively. The mean DUFE was 0·017 (SD 0·007) and 0·012 (SD 0·006) mg/kg per d for the natural-F and low-F groups, respectively. FUFE was lower in the natural-F group (30 %) compared with the low-F group (40 %). Pearson's correlation coefficient for (1) TDFI and DUFE was +0·22 (P= 0·22) and for (2) TDFI and FUFE was − 0·63 (P< 0·001). In conclusion, there was no correlation between TDFI and DUFE. However, there was a statistically significant negative correlation between FUFE and TDFI.

Urinary fluoride excretion in 6- to 7-year-olds ingesting milk containing 0.5 or 0.9 mg fluoride.

Effectiveness of 0.5 mg fluoride (F) milk ingestion in preventing caries has been termed only 'moderate'. In this 3-arm partial cross-over intervention, 32 children aged 6-7 years in a non-F area were recruited and urinary F excretion (UFE) measured before and after ingestion of 0.5 or 0.9 mg F milk. Maintaining customary dietary and oral hygiene habits, children underwent a 2-week 'wash-in' with non-F milk, providing a 24-hour urine sample on day 4 of non-F (baseline) and F milk ingestion containing either (i) 0.5 mg or (ii) 0.9 mg F (intervention). A comparative group of thirteen 6- to 7-year-olds living in fluoridated areas provided a 24-hour urine sample on day 4 of daily non-F milk ingestion, following a 2-week non-F milk wash-in. Valid urine samples were analysed for F and UFE estimated from corrected 24-hour urine volume and F concentration. For the 24 test children providing 2 valid urine samples, mean (95% CI) change in corrected 24-hour UFE was 0.130 (0.049, 0.211) and 0.153 (0.062, 0.245) mg/day for 0.5 mg (p < 0.007) and 0.9 mg F (p < 0.001) groups, respectively. Post-intervention, mean (SD) corrected 24-hour UFE was 0.437 (0.153) mg/day and 0.420 (0.188) mg/day for the 0.5 and 0.9 mg F groups, respectively, which were lower than the WHO provisional standards (0.48-0.60 mg F/day). F milk consumption significantly increased UFE; however, the F content of 0.5 and 0.9 mg F milk may be too low to achieve WHO provisional UFE standards concomitant with optimal F exposure in children aged ≥6 years.

Oral health education and disease prevention in primary dental care: insight from a pilot intervention targeting children aged 0-7 years in northeast England.

This paper outlines a number of issues arising from a primary-care and community-based oral health education (OHE) and disease prevention pilot targeting children aged 0-7 years in County Durham and Darlington during a six month period in 2011-12. The paper highlights the key practical challenges experienced by the NHS dental practices that provided OHE predominantly in community venues and the issues arising for those involved in managing the pilot on a day to day basis. Finally, the paper suggests potential solutions and learning points for dental public health practitioners. The work described in this paper relates to three relevant dental public health competencies: strategy development and implementation; strategic leadership and collaborative working for health and oral health improvement.

Compliance with school F-milk and non-F milk intake in 3 to 4 and 6 to 7-year-old children.

BACKGROUND: Fluoridated (F) milk schemes are employed in six countries to reduce dental caries in children. To maximise their benefits considerable uptake is required. Measuring compliance and understanding contributing factors is important in evaluating the effectiveness of schemes since it can be unclear whether reported sub-optimal fluoride (F) intakes, measured through urinary F excretion, are due to sub-optimal F contents of milks or lack of compliance with consumption. OBJECTIVES: To determine compliance with milk consumption for children receiving non-F or F milk (containing 0.5 or 0.9 mgF per 189 ml carton) and rationalise the use of compliance data for clinical observational or intervention studies involving F milk schemes. RESEARCH DESIGN: Partially randomised, partial cross-over study. PARTICIPANTS: 50 children aged 3-4 and 6-7y consuming non-F (n=50) and F milk (0.5 mgF; n=15 children; 0.9mg F; n=16 children) at school. RESULTS: Mean compliance for both non-F and F milk was > or =90% in each of the groups studied and showed no statistically significant difference for children using both milks. The 95% central range of proportions of milk consumed for groups of individuals was wider for 0.9mgF milk (25% to 100%) than for 0.5 mgF milk (81% to 100%) although the greatest range of variation in compliance for within individual observations was seen for non-F milk consumption and in older children. CONCLUSION: Assessment of compliance with consumption should be included when dental efficacy of F milk consumption is being investigated or evaluated to quantify F exposure from milk. This is important, particularly if a change in the F dose of F milk might be under consideration.

The equity of access to primary dental care for children in the North East of England.

OBJECTIVES: To determine the equity of access to dental care from general dental practitioners for children aged 0 to 17 years. BASIC RESEARCH DESIGN: Postcode data was obtained from the Dental Practice Board for children registered with an NHS dentist. There were 146,180 children aged 0 to 17 years old resident in the study area, these were mapped to their ward of residence. The child registration rate for wards was calculated, using 2001 census data. The level of deprivation for wards was obtained using a standard indicator, the Index of Multiple Deprivation. SETTING: The Durham and Tees Valley Strategic Health Authority area in the North East of England. The Authority has a population of 1.13 million, of which 260,000 were aged 0 to 17, in 2001. There are approximately 170 dental practices in the Authority area contained in 251 Wards. RESULTS: The range of child registration rates in wards was, 11% to 90%. There was a significant negative association between the number of children registered with a dental practice and increasing deprivation. For every 10 point increase in the deprivation score the probability of registration reduced by 5% of the overall rate. The probability of registration reduced less in those wards with a dental practice compared to those without a dental practice with increasing deprivation. CONCLUSIONS: There are significant inequalities in access to dental care. Children living in deprived wards access general dental practices less than those living in wealthier wards. The location of dental practices may reduce inequalities in access.

The relationship between children's dental caries experience and the prescription of general anaesthetics. an evaluation of the effectiveness of a Personal Dental Service Pilot.

OBJECTIVES: To determine if there was a high correlation between the prescription of a general anaesthetic for dental treatment in young children by a Personal Dental Services (PDS) general anaesthetic pilot and the dental health of children at a ward level. BASIC RESEARCH DESIGN: Postcode data from an audit of the single dental general anaesthetic provider in an area was extracted and mapped to individual wards. A proxy for the oral health population was obtained by using the results of a large-scale dental prevalence study of five-year-olds. The wards were ranked into quintiles by dmft and a mean dmft calculated for each. There were 1,406 patients who had a general anaesthetic, 74% were aged 11 years or less. SETTING: A personal dental service dental general anaesthetic pilot in the north of England providing services for a population of approximately 300,000 residents in a non-fluoridated area. RESULTS There was a positive correlation between increasing levels of dental decay in the population and increasing intervention ratios for dental treatment under general anaesthesia (r2 = 0.90). CONCLUSIONS: The PDS pilot provided dental care under general anaesthesia for more patients from wards with poor dental health than from wards with better dental health.

An evaluation of the role played by community pharmacies in oral healthcare situated in a primary care trust in the north of England.

OBJECTIVES: To determine the existing state of oral healthcare advice, products and information provided by community pharmacies in Durham Dales Primary Care Trust area, and determine their potential role in the provision of oral healthcare services. METHODS: A semi-structured questionnaire was devised to examine the current role of community pharmacies in oral healthcare. An interview was arranged with each of the pharmacies. RESULTS: Ninety per cent of pharmacies participated from the Trust area. Common presenting complaints were ulcers and toothache/pain relief. Pharmacists advised customers to see a dentist in 94.1% of cases, 23.5% to see a doctor, 41.2% gave oral hygiene advice and 100% gave short-term pain relief. Pharmacists were keen to improve oral health knowledge. Most were aware of the nearest dental practices but few knew arrangements for emergencies/appointments. There were 14 pharmacists wanting active roles in promotional activities and national campaigns. Issues raised were lack of known key contacts for referrals/advice and lack of support on integration into primary healthcare teams. CONCLUSION: Through new pharmacy contracts and support/education, pharmacists could perform an increased role in oral healthcare provision.

The relationship between dental health and variations in the level of third molar removals experienced by populations.

OBJECTIVE: To determine the relationship between the dental health of populations and the removal of impacted third molars. DESIGN: Data were obtained for the reported episodes of care undertaken in NHS hospitals in England for the surgical removal of third molar teeth and also for the number of removals undertaken in NHS general dental practices in 1994/95. The dental health of the population within the at risk age group for removal of third molars was estimated by using the results of a large scale epidemiological study of twelve-year-old children which took place in 1988/9. The 12-year-old cohort examined would have been 18 years of age in 1994/95. The hospital and general practice data were standardised for age and size of health authority populations and combined on a weighted basis. SETTING: Data were identified which enabled levels of third molar surgery undertaken in the NHS for 23 health authorities in England, to be matched to the estimated dental health of their 18 year old populations. RESULTS: A negative correlation of r2 = 0.24 was demonstrated between the reported prevalence of third molar surgery and the dental health of populations. Surgery increased as the dental health of populations improved. CONCLUSIONS: This study demonstrates that a quarter of the variations in the provision of third molar surgery across health authorities in England is related to differences in the dental health of their populations.

Demand for dental extractions performed under general anaesthesia for children by Leicestershire Community Dental Service.

A study was undertaken on a sample of children who had teeth removed under general anaesthesia by Leicestershire Community Dental service over a six month period. Three hundred and nine subjects were included in the study. The age range was from 2-15 years, 83 per cent of subjects were of European origin and 13 per cent were of Asian origin. Sixty two per cent lived at postal addresses which had positive Jarman scores. Some 52 per cent had been attending their referring clinician for more than a year, while 25 per cent had attended their referring dentist for the first time with the acute problem for which they were referred. Twenty three per cent had had a dental general anaesthetic on a previous occasion, while 46 per cent had never had any restorative care. There is some evidence to show that demand for general anaesthesia is related to positive Jarman scores. The demand for repeat general anaesthesia could be reduced by a more aggressive prescribing of extractions, in children under four.

Distribution of NHS resources for children's dental care in general dental practice in England.

OBJECTIVE: To determine the relationship between the distribution of NHS resources in general dental practice and dental need and access to services for the population in England under the age of 18 in different socio-economic areas. BASIC RESEARCH DESIGN: A proxy for the oral health of under 18 year olds was made from prevalence surveys undertaken on five year old children in each health authority area in 1999/2000. The level of spending per head of the population was ascertained from Dental Practice Board data. Health authorities were grouped according to the eleven United Kingdom Office of National Statistics socio-economic groups. Access was measured by using registration levels of children. SETTING: General dental practices providing National Health Service treatment for children aged 0-18 in England. RESULTS: There was no correlation (r = -0.03) between increasing need for dental care using mean dmft as a proxy and increasing spending per head of the population for each health authority. There was a correlation (r = 0.38) between increasing registration rates and increased spending per head. The populations under 18 had more spent on their oral health care living in areas classified as Mixed Economies, Services and Education and Most Prosperous. Those in Inner London, Manufacturing, Ports and Industry had proportionately the least. The difference between the highest and lowest group was 33%. The groups of Authorities were not homogenous in their level of resources with variations between Authorities in the same groups. CONCLUSIONS: The distribution of NHS resources to general dental practice for people under 18 does not reflect population need. The higher the registration rate for children the greater the amount resources deployed in an area.

The role of pre-general anaesthetic assessment for patients referred by general dental practitioners to the Community Dental Service.

The first aim of this study was first to investigate the effectiveness of seeing patients at a separate appointment prior to any subsequent appointment for the administration of an anaesthetic, for patients referred from general dental practitioners to the Community Dental Service for dental extractions under general anaesthesia. The second aim was to assess the technical adequacy of the information contained in the referrals from general practitioners for the safe provision of extractions under general anaesthesia. The purposes of the assessments were to reduce the number of patients receiving a general anaesthetic, to ensure that the anaesthetist had a satisfactory medical history for the safe administration of an anaesthetic and that the dental officer undertaking the extractions had satisfactory clinical information to undertake the proposed dental care. A sample of records of patients seen at assessment appointments was drawn from a twelve month period. Five hundred and ninety-three patients records were used. One hundred and five cases required further investigations before an anaesthetic could be given. In 264 cases extractions were undertaken as requested by their own dentist, 208 patients had their treatment plans altered, 49 cases had extractions performed with local anaesthesia and 41 cases were discharged without any treatment. The pre-general anaesthetic assessment appointments prevented the need for a general anaesthetic for 15 per cent of referrals from general dental practitioners.